Comparing the Primary Care Performance of
FFS Medicare and Medicare HMOs:
A Longitudinal Study, 1998 to 2006
Ira B. Wilson
William H. Rogers
Hong Chang
Dana Gelb Safran
Background
•
Dramatic increase in MA enrollment from 2003-2009: 5.3
to 10.2M beneficiaries
•
MA costs more than FFS
– on an enrollment weighted average basis payments will be 114% of
those in FFS in 2009
– $12B
•
1998 data showed that, with the exception of financial
access, primary care performance favored FFS c/w HMOs1
•
Previous data showed declines in primary care
performance in Medicare in the late 1990s2
1.
2.
2
Safran et al., Arch Intern Med. 2002;162(7):757-765
Safran DG. Ann Intern Med. 2003;138(3):248-255
Academy Health
June 29, 2009
Study Questions
Longitudinal analyses: 1998 – 2006
•
What is the relative primary care performance of FFS and
HMOs?
•
Do declines persist?
•
Are trends different for FFS and HMOs?
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June 29, 2009
Study of Choice and Quality in Senior Health Care
•
Longitudinal, observational study, started in 1998
•
13 states: AZ, CA, CO, FL, IL, MA, MN, NM, NY, OR, PA,
TX, WA
•
121 HMOs
•
HMO beneficiaries sampled
– Community dwelling
– 65 or older
•
FFS sample matched on age, gender, zip code
– 1:2 FFS: HMO ratio
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Academy Health
June 29, 2009
Data Collection
•
Baseline survey in 1998: n=9,499
•
Follow-ups: 1999, 2000, 2002, 2004, 2005, and 2006
•
Average survey response rate: 75%
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Academy Health
June 29, 2009
Data Sources and Key Variables
•
Data sources: CMS and patient surveys
•
Dependent variables: PCAS variables
–
–
–
–
–
–
–
Visit Based Continuity
Integration
Organizational Access
Financial Access: visit costs, medication costs
Interpersonal Treatment
Communication
Knowledge of the patient
•
Independent variable: system (FFS vs. HMO)
•
Covariates: health status, disease count,
sociodemographic variables, Medicaid status, state
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June 29, 2009
Analyses
•
Analytic problem: beneficiaries switch systems and
change primary care providers
•
Unit of analysis: interval between 2 consecutive surveys
during which patients were in the same system and had
the same physician
– 5,969 individuals who contributed intervals
– 20,966 study intervals
•
Sample weights applied
•
Two periods: pre and post MMA of 2003
– 1998 to 2002
– 2003 to 2006
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June 29, 2009
Results: Baseline Patient Characteristics
N=5,969
Characteristic
All
Demographic characteristics
Age (mean(sd))
74.9 (6.2)
Education (years, mean (sd))
12.8 (2.8)
Gender (% male)
40.5
Race (% white)
88.2
Income (% low income)
39.5
Disease count (mean (sd))
2.0
Physical component score (mean (sd))
42.0
Mental component score (mean (sd))
52.8
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June 29, 2009
HMO
FFS
P-value
74.2 (6.0)
12.5 (2.7)
40.7
85.6
46.2
1.8 (1.5)
42.9 (11.6)
52.9 (9.2)
75.3 (6.3)
12.9 (2.8)
40.5
89.6
35.7
2.1 (1.7)
41.6 (11.9)
52.9 (9.5)
<0.001
<0.001
0.90
<0.001
<0.001
<0.001
0.005
0.94
Organizational Aspects of Care
60
Scale (0-100)
75
95
PCAS Scale Trend
1998
2000
2002
year
Visit Continuity -FFS
Integration -FFS
Organizational Access-FFS
Source: Medicare Study, 1998 - 2006
9
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June 29, 2009
2004
2006
Visit Continuity -HMO
Integration -HMO
Organizational Access-HMO
Organizational Aspects of Care
10
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June 29, 2009
Financial Access
20
Scale (0-100)
35
55
Trend for Financial Access Scale and Items
1998
2000
2002
year
Financial Access -FFS
MD Visits -FFS
Prescription Medicine -FFS
Source: Medicare Study, 1998 - 2006
11
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June 29, 2009
2004
2006
Financial Access -HMO
MD Visits -HMO
Prescription Medicine -HMO
Financial Access
12
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June 29, 2009
Relational Aspects of Care
60
Scale (0-100)
75
95
PCAS Scale Trend
1998
2000
Communication -FFS
Interpersonal Skills -FFS
Knowledge - FFS
Source: Medicare Study, 1998 - 2006
13
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June 29, 2009
2002
year
2004
2006
Communication -HMO
Interpersonal Skills -HMO
Knowledge - HMO
Relational Aspects of Care
14
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June 29, 2009
Summary
•
No changes in relative performance of FFS and HMO
over the 8 years
•
Declines from 1998 to 2002 followed by stabilization or
improvement
•
Patterns were similar in FFS and HMO, except for
financial access
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June 29, 2009
Limitations
•
HMOs only: currently 54% of MA
•
13 states only: currently with 65% of MA enrollees
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June 29, 2009
Conclusions
•
HMOs not delivering extra value commensurate with their
excess cost
•
Declines in primary care performance suggest that
reforms are needed
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June 29, 2009
Funding
•
We are grateful to the organizations that helped to fund
this research, including
– AHRQ
– NIA
– Commonwealth Fund
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June 29, 2009
Outcomes: Death Model
0.60
0.70
0.80
0.90
1.00
Adjusted K-M Survival Curve
0
1000
2000
Analysis Time in Days
HMO
3000
FFS
Adjusted by age gender,race,marrital status,education,poverty status,disease count,medicaid status,STATE
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June 29, 2009
Outcomes: Change in Health Status
Outcome Trend
35
STD 10
45
55
PCS & MCS
1998
2000
2002
year
PCS - FFS
MCS - FFS
Source: Medicare Study, 1998 - 2006
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June 29, 2009
2004
PCS - HMO
MCs - HMO
2006
PCS: Better/Same/Worse Analysis
Predicted %
40
60
80
100
% of Predicted PCS Better, Same and Worse
NS
56.8
55.3
NS
20
42.3
42.4
NS
15.3
0
15.3
Better
Same
HMO
Worse: % of worse or dead
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June 29, 2009
Worse
FFS
MCS: Better/Same/Worse Analysis
80
100
% of Predicted MCS Better, Same and Worse
Predicted %
40
60
NS
68.5
20
66.8
NS
NS
18.4
14.4
16.8
0
14.4
Better
Same
HMO
Worse
FFS
NS: p value to compare FFS vs. HMO not significant; *: p value to compare FFS vs. HMO < 0.05
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June 29, 2009
Background
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June 29, 2009
Baseline PCAS Scores
1998
HMO
FFS*
PCAS Scale
All
Organizational aspects of care
91.0 (0.3)
Visit based continuity
74.9 (0.4)
Integration
63.7 (0.4)
Organizational access
88.3 (0.4)
72.7 (0.4)
61.6 (0.4)
93.1 (0.5)
76.5 (0.6)
65.3 (0.6)
-4.80 (p<0.001)
-3.80 (p<0.001)
-3.70 (p<0.001)
Financial access
Full financial assess scale
Doctor visit item
Medication item
40.6 (0.5)
47.3 (0.4)
35.9 (0.5)
46.2 (0.3)
52.0 (0.3)
41.3 (0.4)
37.0 (0.7)
44.2 (0.7)
32.4 (0.8)
9.20 (p<0.001)
7.80 (p<0.001)
8.90 (p<0.001)
Relational aspects of care
Communication
Interpersonal treatment
Knowledge of Patient
79.2 (0.3)
74.4 (0.4)
66.7 (0.4)
77.2 (0.3)
72.1 (0.4)
63.5 (0.4)
80.5 (0.4) -3.30 (p<0.001)
76.2 (0.5) -4.10 (p<0.001)
68.9 (0.6) -5.40 (p<0.001)
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June 29, 2009
Difference
PCAS Scores: 2006
25
PCAS Scale
All
Organizational aspects of care
84.5 (0.7)
Visit based continuity
73.4 (0.6)
Integration
65.2 (0.6)
Organizational access
82.1 (0.9)
71.3 (0.7)
63.1 (0.7)
86.2 (0.9)
74.6 (0.8)
66.7 (0.8)
-4.10 (p=0.001)
-3.30 (p=0.002)
-3.60 (p<0.001)
Financial access
Full financial assess scale
Doctor visit item
Medication item
39.0 (0.6)
45.0 (0.6)
32.9 (0.8)
41.5 (0.6)
46.7 (0.7)
35.9 (0.9)
37.4 (0.8)
44.0 (0.8)
31.2 (1.1)
4.10 (p<0.001)
2.70 (p=0.011)
4.70 (p<0.001)
Relational aspects of care
Communication
Interpersonal treatment
Knowledge of Patient
75.8 (0.6)
72.6 (0.6)
68.7 (0.6)
74.9 (0.6)
70.7 (0.7)
67.1 (0.7)
76.4 (0.8)
74.0 (0.8)
69.9 (0.8)
-1.50 (p=0.13)
-3.30 (p=0.002)
-2.80 (p=0.008)
Academy Health
June 29, 2009
HMO
2006
FFS*
Difference